A little boy in foster care is dead by his own hand, but a poorly functioning child welfare system also is responsible. Last month, 7-year-old Gabriel Myers hanged himself on an extendable shower hose while in a South Florida foster home. At the time he was taking a combination of psychotropic medications, one of which carries a warning that it might lead to suicidal behavior in children. State law was ignored in giving the child the medicines without consent from his mother or a judge. In the final outrage, this child was given risky drugs but not the intense attention he so obviously needed.

St. Petersburg Times staff writer Kris Hundley reported that at the time of his death, Gabriel was taking Vyvanse, an ADHD drug, and Symbyax, a combination antipsychotic and antidepressant, which warns of heightened suicide risk in children particularly when first prescribed.

Six times, Gabriel's caseworker had documented that the Department of Children and Families had parental consent for the medication. But there was no such consent. Gabriel's mother signed a general medical authorization on the same day she was found unconscious in her car with powder cocaine, crack and oxycodone in her possession. But when a child is in state custody, a parent must give explicit consent after being "expressly informed" about changes in a child's medication, including being told of medications' benefits and risks and about alternative treatments.

That never happened in Gabriel's case, and it appears this case is not unique. It has been a common practice for DCF workers and physicians to fail to obtain parental consent when a psychotropic drug is for a nonpsychotherapeutic use, under the mistaken impression that the law didn't require it.

And foster care advocates say that DCF's internal records are abysmal in tracking children taking psychotropic medications. This also suggests that proper consents are not being obtained.

DCF Secretary George Sheldon is responding appropriately to Gabriel's tragic death. He is closing the loophole that allowed the prescribing of mood-altering drugs without parental consent. He has named an impressive committee to investigate Gabriel's death and make recommendations. Sheldon also made public the details of Gabriel's situation rather than try to cover up DCF's failings. That alone bodes well for an honest accounting and a sincere desire to reform.

But to prevent a similar situation, Sheldon will have to look beyond a caseworker's failure to inform a parent and address a system's failure to adequately meet Gabriel's needs.

Gabriel said he had been a victim of sexual abuse before moving to Florida, which means he should not have been placed in any foster home where there were small children present. As Gabriel started engaging in inappropriate touching, he was bounced from one foster placement to another to protect other children. This kind of shuffling can add trauma to a child who is already at risk.

Gabriel also didn't receive all the behavioral therapy he needed, and he lost the therapist with whom he had established a relationship. Sheldon noted that in the days before his suicide Gabriel changed medications, moved to a new foster home and received a new therapist.

Sheldon has it right when he says that Gabriel's death "ought to mean something." State law needs to be followed when prescribing medication for children in foster care. And particularly when it comes to damaged children, there has to be a recognition that drugs are no substitute for basic human care and attention.

Where to get helpCCHR.ORG is about the best place I know of to get help or referrals on psychiatric abuse.
Dr. John Breeding also runs an interesting site, Wild Colts, for kids diagnosed with ADHD (one of the greatest frauds I've seen).